Provider Demographics
NPI:1255517629
Name:HEISENFELT, MOLLY (LICSW)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:HEISENFELT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002036Medicare Oscar/Certification